The Field Guide to Understanding Human Error, 2nd Edition

16 Making Recommendations

Coming up with useful recommendations can be difficult. Sometimes only the shallowest of remedies seem to lie within reach. Tell people to watch out a little more carefully. Write another procedure to regiment their behavior. Or just get rid of the particular miscreants altogether. The limitations of such countermeasures are severe and deep, and well-documented:

• People will only watch out more carefully for so long, as the novelty and warning of the mishap wears off;
• A new procedure will at some point clash with operational demands or simply disappear in masses of other regulatory paperwork;
• Getting rid of the miscreants doesn’t get rid of the problem they got themselves into. Others always seem to be waiting to ...